Sangoma to mainstream services

Cape Town is a beguiling city of immense
beauty and horrendous contrasts. More than any place I have ever
been, there is a sinister level on which you can live here, unaware
of the suffering going on around the corner. Drink a mojito with
royalty on Camp’s Bay, get your Maserati serviced, eat lobster with
the rich and famous – just don’t take a wrong turn down the N2 and
end up in Khayelitsha.

Or Gugulethu, or other evocatively named
townships like Brixton, Barcelona or Malibu Village. This is the
legacy of apartheid, in which Black and ‘Coloured’ families were
uprooted from their homes in the city, like the vibrant and now
infamous District 6, which was bulldozed to the ground. Township
housesThese families were removed from the sight of ‘White-only’
areas and relocated to hostels without basic amenities, or schools,
or healthcare. This explains why so much of the city’s deprivation
and destitution seems conveniently located out of sight of the
Table Mountain Cable Car, the Mount Nelson Hotel and the penguins
on Boulder’s Beach.

This is why the community clinics run by
psychiatric registrars and consultants within the townships are
such an important part of healthcare in post-apartheid South
Africa. The majority of doctors are White and there is a deep
symbolism to the act of them travelling into the townships (where
they certainly do not live) to diagnose and treat their patients.
Here, listening to Afrikaans questions translated into the magical
clicks of Xhosa, was where I observed truly holistic psychiatric
medicine – and gained a small sense of the deprivation in which the
majority of Cape Town’s residents live.

It’s not easy to take a psychiatric history
with one or two language barriers between you, the nurse
interpreting and your patient. A lot of the meaning of what you
want to ask seems lost in translation. And your cultural conception
of their symptoms might be different to theirs. While in Cape Town,
most patients embraced the medical model to a degree, and did not
dispute the role medication played in their recovery, it was not
the only treatment they sought. Many patients first looked to their
sangoma (traditional healer) for support and advice. Often, after
little success, the sangoma would refer them to mainstream services
and doctors even spoke of successfully working alongside a sangoma,
whose role was more one of social support than one of ‘healer’. But
other, less reputable members of this unregulated specialty were
known to prescribe hallucinogenic drugs which worsened psychotic
symptoms, or even advocate painful and disfiguring procedures to
‘banish the demon’ to which they were attributed. Psychiatrists in
community clinics had to work together with the patient’s cultural
as well as religious belief system in order to engage patients with
a rather alien biological model of their distress. The second
enlightening aspect of community psychiatry in Cape Town was the
realisation that when statutory mental health services are
under-resourced, the burden of care lies truly with the patient’s
family.

The epitome of this overwhelming
responsibility was encapsulated by the predicament of Mrs F. She
financially supported and cared for her niece (since her sister had
died), who had managed to stay out of hospital despite many
previous admissions for bipolar disorder, and her daughter, who had
learning disabilities. She also supported her own children, one of
whom caused her anxiety through his involvement with knife crime in
a local gang.

She had nursed her own mother until her
death and then her husband until his death from cancer. She worked
nights cleaning offices and spent most of her day taking care of
the small, meticulously well-kept flat she shared with her family
in the township of Athlone. My first thought was “when does she
sleep?” She doesn’t sleep much. You wondered how she coped with so
much. But as you looked around the lovingly polished photographs of
all these different children, siblings, nieces and cousins – you
could see exactly why she did it. She knew that if she didn’t keep
things together, many inter-connected lives, held together so
tenuously, would fall apart. The extent of sacrifice and care Mrs F
represented was incredible to witness. But the enormous burden she
bore, for which she had previously been admitted to a psychiatric
ward, took its toll. Mrs F’s suffering was the result of
deinstitutionalisation, without the creation of community services
to support the needs of discharged patients. Her sacrifice was
wonderful, but grossly unfair. It was symptomatic of the historic
abandonment of the people of the townships – left to bear the
social ills created by the very regime that then refused to help.
This was why it meant so much that White doctors got in their cars
and came to the clinics and visited the houses of their patients –
rather than staying within the mansion walls of Groote
Schuur.

Cape Town is a beautiful place. Surrounded
on three sides by dramatic coastline and stunning beaches, you can
surf, scuba and whale-watch (or cage dive) to your heart’s content.
But when you visit the Two Oceans Aquarium on the waterfront, look
out for the sign that tells you everything you need to know: “80%
of Cape Town’s children have never seen the sea.”

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About this blog

Roxanne Keynejad is a final year graduate
entry Medicine student at King's College London, having studied a
first degree in Psychology with Philiosophy at the University of
Oxford.

She is spending four weeks of her elective
studying psychiatry at Groote Schuur and Valkenberg Hospitals, Cape
Town, for which she received bursaries from the Royal
College of Psychiatrists elective bursary fund and the Institute of
Medical Ethics.